Improving Client Safety: Strategies to Prevent and Reduce Practice Errors in Occupational Therapy

Keli Mu; Helene Lohman; Linda S. Scheirton; Teresa M. Cochran; Brenda M. Coppard; Stephanie R. Kokesh

doi:10.5014/ajot.2011.000562

Abstract

OBJECTIVE. This qualitative focus group study investigated the strategies to prevent or reduce practice errors used by occupational therapists who practice in physical rehabilitation and geriatrics.

METHOD. A total of 34 occupational therapists from four geographic regions across the United States participated in four focus groups. Participants worked in the areas of physical rehabilitation or geriatrics and had a minimum of 1 year of practice. Participants responded to open-ended, guiding questions. Data collected from the focus groups were analyzed qualitatively for themes.

RESULTS. Analysis of the collected data yielded four themes related to specific strategies occupational therapists use to prevent or reduce practice errors: (1) strengthen orientation and mentoring for new therapists, (2) ensure competency through performance competency checks, (3) enhance existing or establish new safety policies and procedures, and (4) advocate for the profession and for systemic change.

CONCLUSION. Findings of the study suggest that occupational therapists implement various discrete strategies to prevent or reduce practice errors and improve client safety. Occupational therapy practice and professional training must emphasize the inevitability of practice errors; the importance of orientation and training, including assertiveness training; and the inclusion of performance-based competency checks.

The publication in 2000 of the Institute of Medicine (IOM) report To Err Is Human: Building a Safer Health System significantly increased both professionals’ and the public’s awareness of medical error and patient safety and drew considerable attention to this important topic. Policymakers, health care providers, researchers, and educators, as well as many public and private organizations and agencies, have devoted tremendous resources and effort to help increase understanding of ways to prevent or reduce medical errors and improve patient safety. Subsequent IOM publications, Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2001) and Patient Safety: Achieving a New Standard for Care (IOM, 2004), added further momentum to such efforts.

Research on patient safety has grown exponentially in health care professions such as medicine, nursing, and pharmacy, leading government and private agencies to focus considerable resources on the subject (Agency for Healthcare Research and Quality, 2010a;Jha, Prasopa-Plaizier, Larizgoitia, & Bates, 2010; Joint Commission, 2010b; National Patient Safety Foundation, 2010; U.S. Department of Veterans Affairs, 2010; World Health Organization, 2009a, 2009b). Such research in occupational therapy and physical therapy, however, is still limited (Cochran, Mu, Lohman, & Scheirton, 2009; Deusinger, 1987, 1992; Mu, Lohman, & Scheirton, 2006; Scheirton, Mu, & Lohman, 2003). In the United States alone are >104,000 practicing occupational therapists and >185,000 physical therapists (Bureau of Labor Statistics, 2010).

As in other health care professions, practice errors do occur in occupational therapy and physical therapy (Cochran et al., 2009; Deusinger, 1987, 1992; Mu et al., 2006; Scheirton et al., 2003). Starting in 2001, with the support of the Health Future Foundation and the National Patient Safety Foundation, we initiated a series of research studies to examine the phenomenon of practice errors in occupational therapy and physical therapy practice. Previous studies in occupational therapy suggested that occupational therapists make errors in practice and that the errors they make vary considerably (Lohman, Mu, & Scheirton, 2004; Mu et al., 2006; Scheirton et al., 2003), ranging from minor errors (e.g., ripping fingernails or causing patient fatigue) to severe ones (e.g., rupturing tendons or leaving a hot pack on too long, resulting in burns; Mu et al., 2006). Errors can be classified as technical errors or moral errors. Technical errors concern methods, skills, or approaches that lead to physical harm to clients—for example, exceeding client limitations after a hip replacement. Moral errors relate to behaviors that undermine the practitioner–client relationship or are ethically inconsistent—for example, providing an unneeded service to obtain payment or being untruthful by exaggerating the level of function that can be accomplished through therapy (Lohman et al., 2004; Mu, Lohman, & Scheirton, 2005).

In previous studies, most practice errors occurred during the intervention phase of the occupational therapy process (Mu et al., 2006). Fewer years of occupational therapy work experience were associated with the types and frequency of errors made; inexperience or inadequate knowledge was more often linked to error commission. Moreover, organizational culture and responses to practice errors affected occupational therapists’ strategies for addressing errors; for example, those who feared disciplinary action were less likely to openly report or disclose errors on a timely basis.

Although previous research has begun to explore the strategies occupational therapists use to prevent and reduce practice errors, no study has had such strategies as its exclusive focus. In the current study, we used the focus group method to examine the specific and discrete strategies occupational therapists use to prevent and reduce practice errors and improve client safety.

Method

Research Design

We used a focus group design because it is ideal for exploring and examining subjective perspectives and experiences in a neutral, nonthreatening way (Krueger & Casey, 2000; Morse & Field, 1995). The study was approved by the institutional review board at Creighton University. All participants provided informed consent to participate in the study.

Participants

Occupational therapists practicing in physical rehabilitation or geriatrics across the United States participated in four focus groups, each lasting about 90 min. Participants were registered occupational therapists who met the following three criteria: (1) were currently practicing or had practiced in physical rehabilitation or geriatrics, (2) had a minimum of 1 yr practice experience in their field, and (3) were willing to participate in the study to share their experience. The study was limited to occupational therapists working in the physical rehabilitation or geriatrics practice settings for two reasons: (1) Practice settings in occupational therapy vary considerably, and focusing on physical rehabilitation or geriatrics minimized the variability, and (2) physical rehabilitation and geriatrics are among the largest practice areas in occupational therapy (American Occupational Therapy Association [AOTA], 2006).

Procedures

All four focus groups were conducted at sites and times that were convenient to the participants. Two focus groups took place in Nebraska and Colorado, and two other focus groups, one with participants from New York and the other with participants from North Carolina, were conducted at the AOTA Annual Conference & Expo in North Carolina. Each focus group lasted about 1.5 hr.

Focus groups were moderated by two members of the research team (Keli Mu and Helene Lohman); one served as the facilitator and the other operated the tape recorder and took notes. The facilitator used a list of semistructured interview questions to guide the focus groups; this list was based on an extensive literature review, our own educational and clinical experience and previous research, and input from local occupational therapists. The initial guiding questions were as follows:

1)Describe an event in a physical rehabilitation or geriatrics setting that you consider to be an occupational therapy practice error.
2)In your opinion, what caused this error?
3)What did you do afterward?
4)What could you have done differently that could have prevented its happening?
5)What discrete strategies have you used or have you seen others use to prevent or reduce practice errors?

At the beginning of each focus group, the facilitator introduced the study and informed participants that the purpose of the focus group was to explore the specific and discrete strategies occupational therapists use to prevent or reduce practice errors and improve client safety. The facilitator also informed participants that the study had been approved by the Creighton University Institutional Review Board and that all information obtained would be kept strictly confidential. All participants completed a demographic information form before the start of the focus group. With permission from all participants, the other research team member audiotaped the focus groups. At the conclusion of each focus group, the facilitator invited participants to ask questions and seek any necessary clarification.

Data Analysis

After each focus group, a professional transcriber immediately transcribed all recorded discussions. The primary investigator (Keli Mu) then reviewed the transcripts and conducted random spot checks (i.e., randomly chose and listened to three sections of a recorded tape) to verify the accuracy of the transcription. Then two investigators (Keli Mu and Helene Lohman) independently analyzed the data and discussed the findings before the next focus group took place. They also distributed and discussed the field notes among themselves after each focus group and hand wrote major conclusions generated from the field notes in the margins of each transcription. Findings from each focus group were used to modify (e.g., add, rephrase) interview questions for subsequent focus groups. For example, during the first focus group, many participants noted the importance of mentorship for new graduates because inexperience is one of the main causes of errors. In subsequent focus groups, the investigators added a question related to mentorship and prevention of errors. In the second focus group, several participants articulated the value of instituting competency checks for therapists at their sites, so the investigators added a question on the use of competency checks for the subsequent focus groups.

Keli Mu and Helene Lohman analyzed all transcribed data using a synthesis of strategies for qualitative data analysis (Bogdan & Biklen, 2006; Denzin & Lincoln, 2003; Morse & Field, 1995). They first independently and separately coded the text units and generated initial coding categories. They then met to examine and compare printouts of the initial categories with the pertaining text units. When the investigators discovered discrepancies, they reexamined the data and discussed the findings until they reached a consensus. They then compared, contrasted, expanded, condensed, or refined the categories to yield the final coding categories. Finally, they examined the relationships among the categories to yield themes of the study (Bogdan & Biklen, 2006; Denzin & Lincoln, 2003; Morse & Field, 1995). The investigators used NVivo (Version 7; QSR International Pty Ltd., Doncaster, Victoria, Australia), a qualitative data analysis software program, to aid the data analysis.

Results

A total of 34 occupational therapists (31 women, 3 men) from four states representing four different regions of the United States—Colorado, Nebraska, New York, and North Carolina—took part in the study. Eleven participants held a master’s degree, and 4 had a doctoral degree (doctorate of occupational therapy); the remaining participants did not provide degree information. Eighteen participants were currently practicing or had practiced in a physical rehabilitation setting, 7 were currently practicing or had practiced in a geriatrics setting, and 7 were practicing or had practiced in both settings (data for 2 participants were not reported). Demographic information is presented in Table 1. Analysis of the collected data yielded four themes: (1) strengthen orientation and mentoring for new therapists, (2) ensure competency through performance competency checks, (3) enhance existing or establish new safety policies and procedures, and (4) advocate for the profession and for systemic change.

Table 1.

Participant Demographic Information

Characteristic	n	%
Gender
Male	3	8.8
Female	31	91.2
Age
20–29	2	5.9
30–39	7	20.6
40–49	14	41.2
50+	11	32.4
Practice area
Geriatrics	7	20.6
Physical rehabilitation	18	52.9
Both	7	20.6
No data	2	5.9
Experience, mean yr
Geriatrics	6.8
Physical rehabilitation	14.6
Location
Colorado	12	35.3
Nebraska	9	26.5
New York	6	17.6
North Carolina	7	20.6

View Large

Table 1.

Participant Demographic Information

Characteristic	n	%
Gender
Male	3	8.8
Female	31	91.2
Age
20–29	2	5.9
30–39	7	20.6
40–49	14	41.2
50+	11	32.4
Practice area
Geriatrics	7	20.6
Physical rehabilitation	18	52.9
Both	7	20.6
No data	2	5.9
Experience, mean yr
Geriatrics	6.8
Physical rehabilitation	14.6
Location
Colorado	12	35.3
Nebraska	9	26.5
New York	6	17.6
North Carolina	7	20.6

Strengthen Orientation and Mentoring for New Therapists

One strong theme elicited from the focus group discussions was the need to strengthen orientation and mentoring for newly hired occupational therapists. Participants believed that strengthening on-site orientation for new employees is an effective strategy for error prevention and reduction. In addition to a general orientation to the hospital, clinic, or nursing facility, participants suggested that site-specific orientation to areas in which errors occur more often can help reduce and prevent errors. One participant commented regarding new employee orientation, “You have your emergency preparedness stuff that you get in your big orientation, and then you have department-specific orientation, and ‘Here is how to handle these OT-specific types of things.’” Another participant described how she oriented new therapists to specific skills, such as transfer training:

Well—for example, with transfers—we have new employees. Even if they’ve got some experience, we have one of the [assistants] we’ve designated as skilled in transfer training… . I set up with him for 30 min to go over basic transfers. ‘I don’t want you to move your back this way; if this patient presents like this, this is the way we want you to do it … and now you lift me and I lift you.’ So there’s a lot of hands on.

All participants agreed that important areas for orientation need to be identified on the basis of data and input from administrators, safety personnel, occupational therapists, and other stakeholders.

Participants repeatedly emphasized the significance of mentorship for new occupational therapy graduates and experienced occupational therapists who enter new practice areas. To motivate and encourage seasoned occupational therapists to serve as mentors, participants suggested that continuing education credits be offered for mentoring. Others suggested that occupational therapy associations at both the national and the state levels create discussion boards on their Web sites as platforms for entry-level occupational therapists to seek help, obtain answers, and acquire mentors. One participant stated, “What I think would help would be a national or state mentoring system where people who graduate get a mentor… . The only thing it can do is help improve our profession.” Another therapist described mentoring as a coaching process:

Coaching done properly is helpful … . I am more [in favor] of the coaching model and trying not to instill the fear because you want people to learn. And you want them to come if there’s an error, and you want them to say, “I don’t know how to do this.” [Mentoring should include] very carefully molded coaching [and] knowledge of how to coach people and how to grow them.

Participants expressed strong concerns about new graduates practicing in rural areas. They believed that new graduates should either not seek rural practice as their first employment setting or develop a network with experienced occupational therapists in the region or state to obtain mentorship when it is needed.

Ensure Competency Through Performance Competency Checks

A second theme elicited from the focus group participants was related to ensuring competency through regular performance-based competency checks parallel to continuing education and in-service opportunities. Many of the therapists asserted that such checks, in addition to in-services and continuing education, would help prevent and reduce practice errors and thereby improve client safety in turn.

This theme reflected participants’ concern that merely attending an in-service or continuing education opportunity does not guarantee competency or skill acquisition. Participants strongly advocated for performance-based competency checks as a way to improve the outcomes of such training. They noted that competency checks were especially essential for uncommonly applied skills, such as administering physical agent modalities, or newly acquired skills, such as use of a recently purchased item of equipment.

One participant described how her facility maintained competency:

We have a huge competency program that we have set up that is population and technique specific … . We have these populations—diagnostic groups—and all these interventions. You don’t get assigned a specific case until you have gone through a certain level of competency … . It’s a very systematic way … and I would say that in the 3 years that I’ve been in the same facility, I haven’t seen so-called practice errors.

Participants were particularly concerned with ensuring the competency of new graduates. One participant articulated the following: “You know, they [students] do it and learn; they get exposure. That’s not competency, however. So until we have to sit in the clinic, until you’ve taken some continuing education courses … you don’t have competency in that area.”

Enhance Existing or Establish New Safety Policies and Procedures

Capitalizing on the facility’s existing safety infrastructure is an important means of preventing or reducing practice errors. Participants spoke positively about the safety infrastructure in their facilities, which included safety committees and quality assurance offices that provide safety orientation and in-service training for occupational therapists, educate patients, and collect practice error data. Participants applauded the role of the Joint Commission (2010a) accreditation standards in reducing error and improving patient safety, particularly the requirement that professionals use two methods to verify the patient’s identity before beginning work with the patient. One therapist provided the example of colored armbands and room and chart markers to alert staff to patients at risk for a fall.

Participants also cited data-based initiatives that led to new policies and procedures. Examples they provided included a policy to require occupational therapists to see the written order and physician’s signature before they begin treatment and a committee to address patient skin integrity.

Advocate for the Profession and for Systemic Change

Many participants strongly believed that taking action to advocate for the occupational therapy profession and for systemic change would reduce practice errors caused by systemic (not individual) failures. For instance, while discussing practice errors caused by productivity pressure, participants maintained that therapists need to provide error information to administrators and insurance agencies to help them formulate more reasonable productivity expectations. In addition, they cited advocacy for the profession to insurance companies as necessary to ensure that patients are discharged after receiving all the care they need rather than according to a predetermined window. Practice errors are more likely to occur when therapists face shortened hospital stays and reimbursement pressures (Sandstrom, Lohman, & Bramble, 2009).

Participants noted the need for professional advocacy to ensure a high standard of professional education and prepare caring, ethical, and competent therapists. Participants stressed that committing to lifelong learning and taking initiative to seek information and explore solutions to unexpected situations are essential for effectively dealing with ambiguous and uncertain situations that may lead to practice errors. One participant offered the following example of how professional education can prepare therapists for practice in different situations:

As an educator, I think it’s really important in occupational therapy school that we train our students on all different kinds of documentation… . So that if I’m going to work a PRN [as-needed] job and I go into a skilled nursing facility, I should know what those kinds of forms look like and where I’m going to write things and where to find things. And if I’m going to go into an acute hospital I should know about that … and then if I’m going to go into rehab… . They’re all totally different ways of documenting. You need to talk about where information is, and where to get it, and where to put it for other people to read.

Participants also highlighted the value of assertiveness training during professional education in enabling occupational therapy practitioners to avoid practice errors. When encountering a unique case or being required to provide unfamiliar treatment, practitioners should not be afraid to say no (e.g., by referring the client to a more experienced therapist or declining to provide the treatment). Occupational therapy practitioners cannot know everything and be competent in everything; admitting one’s incompetency is a competent act. As 1 participant stated, “You need to know when to ask for help, or tell your supervisor, … ‘I’m not comfortable doing that.’” Another observed,

Therapists know what’s right and wrong, but their work is putting them in situations and requiring them to do things. And it is very difficult for someone who needs their job to tell their companies they’re not going to do what they’re being told.

Being assertive on a health care team and in a hierarchical environment is especially crucial when an order or referral from a physician or other health care provider is not clear or is inaccurate. Occupational therapists must take the initiative to verify such orders before beginning treatment or defer the treatment pending clarification. Participants argued that such skill training must start with professional education.

Discussion

With this research, we begin to move the literature beyond consideration of the causes, types, and contributory factors of practice errors to the development of preventive strategies. The findings are rich with practical ideas that can be applied to education and practice.

The theme of strengthening orientation and mentorship of new therapists or therapists new to practice areas echoes earlier research findings that practice errors occur more commonly during the first few years of practice. Occupational therapy administrators should consider establishing or strengthening safety-related orientation and mentoring in their facilities. Training for mentors could occur nationally through AOTA workshops or through state associations and should become a strong value endorsed by the profession.

The theme of ensuring competency through performance competency checks can be implemented at the professional education level and continue into practice. Occupational therapy students should practice reporting errors during their professional education so that error reporting is a familiar practice when transitioning from student to practitioner. Additionally, if students are regularly exposed to reporting errors, instituting investigative root cause analyses of errors, and undergoing competency checks in their professional education, these activities would become part of their professional socialization and lifelong learning routines.

Managers can assist in creating a culture of safety by developing mechanisms for optimizing teamwork and strengthening communication, developing safety-related policies, standardizing processes, building in redundancies, conducting competency checks related to key error issues in practice, and systematizing reporting and learning from errors. Establishing a procedure for reporting errors and maintaining a good record system for competency checks can help with these activities. The procedure for reporting errors should offer an opportunity to discuss the incident and its antecedents, context, and results in a candid, honest, and trust-engendering process. Analysis of the error can lead to a collaborative effort for prevention of future errors.

As one patient safety expert has noted (Vincent, 2006), in any organization, many factors contribute to the formation of a safety culture, including individual and group values, attitudes, competencies, and patterns of behavior. Such factors collectively determine the commitment to and the style and proficiency of the organization’s health and safety program. It takes time to create a culture, develop a system of error reporting, and perform competency checks, but the cost–benefit outcome will likely prove worth the effort. Managers who are developing policies and procedures to promote a safety culture should be aware of existing recommended structures for patient safety, such as the Joint Commission’s (2010a, 2010b) patient safety–related initiatives and standards.

A functional national database for error reporting is needed. The Patient Safety and Quality Improvement Act of 2005 established patient safety organizations (PSOs) to collect, aggregate, and analyze voluntarily submitted confidential information reported by health care providers, including occupational therapy practitioners. As these PSOs become fully operational (most were established in 2009), they will report deidentified patient safety data directly to the government’s Network of Patient Safety Databases in an effort to identify patterns of safety failures and propose measures to eliminate or reduce patient safety risks and hazards. Additionally, data on occupational therapy competency measures could be collected at the national level and housed, for example, on the AOTA Web site for access by AOTA members. Having readily available measures to check competency would reduce the time required to create such tools and increase networking among tool creators and users.

Lack of assertiveness when communicating about patient errors was found in earlier studies on patient errors in occupational therapy and was further confirmed in this study. Lack of assertiveness also results in ethical issues in practice (Mu et al., 2006; Scheirton et al., 2003). Being able to say no to inappropriate orders or to defer treatment to another therapist who has competency in that particular practice area should be simulated and learned in professional education. Standard 5, Ethical Practice, of the AOTA Standards for Continuing Competence asserts, “Occupational therapists and occupational therapy assistants shall identify, analyze, and clarify ethical issues or dilemmas to make responsible decisions within the changing context of their roles and responsibilities” (AOTA, 2010, p. S104).

Occupational therapy professional organizations such as AOTA and the Accreditation Council for Occupational Therapy Education (ACOTE) play an important role in developing educational standards that promote patient safety. The current ACOTE standards specifically address communication skills (B.1.1, B.5.18) and patient safety (A.4.11, B.2.8, B.5.2, B.5.16; ACOTE, 2010). Other AOTA entities, such as the Commission on Education, which (among its many charges) focuses on educational trends, and the Commission on Practice, which looks at quality and standards for occupational therapy practice, might address patient safety issues if this area is perceived as an educational or practice focus (AOTA, n.d.). Thus, changes to promote a culture of patient safety with error prevention can develop both bottom up, at an educational and practice level, and top down, from AOTA and other national entities such as the Joint Commission.

Professional education could include role plays and offer experiences in which students encounter an inappropriate referral or a situation in which they ought to defer a particular treatment to a more qualified practitioner. Such educational experiences will increase the chances of their using assertive communications when they become practitioners faced with similar situations. Professional journals should consider dedicating a special issue to practice errors and error prevention.

Because patients’ needs and health care environments are so complex, even the most highly trained, skilled, and experienced health care providers make errors (Mu et al., 2006). It is essential to shift the prevention mindset from perfectionism to error inevitability. Participants in this study offered discrete strategies for preventing or reducing errors while creating a nonpunitive, supportive culture and environment that promote honesty and learning. In addition, establishing a national reporting system for occupational therapy practice errors will enable professionals to learn from the errors of others, thus improving practice and patient safety.

Limitations and Future Research

Several limitations exist in this study. Foremost, although efforts were made to ensure the homogeneity of participants, as many researchers have suggested (Krueger & Casey, 2000; Morse & Field, 1995), participants varied greatly in years of practice experience and type of setting. Second, social desirability might have affected participants’ points of view despite our efforts to minimize such impact. Finally, caution should be taken in transferring the findings to other populations and practice settings (Krefting, 1991).

Future studies are warranted to investigate the practice error prevention and reduction strategies used by occupational therapists who practice in other settings, such as schools, and the similarities and differences in strategies across settings. Future research should also examine the impact of implementing discrete and specific strategies on practice error prevention and reduction. Additionally, efforts should be made to examine the outcomes of educational training on students’ understanding of and preparation for error prevention and reduction in their future practice.

References

Accreditation Council for Occupational Therapy Education. (2010). Accreditation Council for Occupational Therapy Education (ACOTE) standards and interpretative guidelines. Retrieved June 3, 2011, from www.aota.org/Educate/Accredit/StandardsReview.aspx

Agency for Healthcare Research and Quality. (2010). Patient Safety Network (PSNet). Retrieved May 21, 2010, from www.psnet.ahrq.gov/

American Occupational Therapy Association. (2006). 2006 occupational therapy compensation and workforce report. Bethesda, MD: AOTA Press.

American Occupational Therapy Association. (2010). Standards for continuing competence. American Journal of Occupational Therapy, 64(6, Suppl.), S103–S105. doi: 10.5014/ajot.2010.64S103

American Occupational Therapy Association. (n.d.). Leadership opportunities. Retrieved June 30, 2010, from www.aota.org/Governance/Leadership.aspx

Bogdan, R., & Biklen, S. (2006). Qualitative research for education: An introduction to theory and methods (5th ed.). Boston: Allyn & Bacon.

Bureau of Labor Statistics. (2010). Occupational therapists. In Occupational outlook handbook, 2010–2011. Retrieved July 23, 2010, from www.bls.gov/oco/ocos078.htm

Cochran, T. M., Mu, K., Lohman, H., & Scheirton, L. S. (2009). Physical therapists’ perspectives on practice errors in geriatric, neurologic, or orthopedic clinical settings. Physiotherapy Theory and Practice, 25, 1–13. doi: 10.1080/09593980802622685 [PubMed]

Denzin, N. K., & Lincoln, Y. S. (Eds.). (2003). Collecting and interpreting qualitative materials (2nd ed.). Thousand Oaks, CA: Sage.

Deusinger, S. S. (1987). Errors in clinical practice: A critical incident survey of physical therapists in Missouri. Dissertation Abstracts International, 48, 04B.

Deusinger, S. S. (1992). Analyzing errors in practice: A vehicle for assessing and enhancing the quality of care. International Journal of Technology Assessment in Health Care, 8, 62–75. doi: 10.1017/S0266462300007923 [Article] [PubMed]

Institute of Medicine. (2000). To err is human: Building a safer health system. Washington, DC: National Academies Press.

Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academies Press.

Institute of Medicine. (2004). Patient safety: Achieving a new standard for care. Washington, DC: National Academies Press.

Jha, A. K., Prasopa-Plaizier, N., Larizgoitia, I., & Bates, D. W. (2010). Patient safety research: An overview of the global evidence. Quality and Safety in Health Care, 19, 42–47. doi: 10.1136/qshc.2008.029165 [Article] [PubMed]

Joint Commission. (2010a). Accreditation program: Long term care, national patient safety goals. Retrieved June 2, 2011, from www.jointcommission.org/assets/1/6/2011_NPSGs_LTC.pdf

Joint Commission. (2010b). Patient safety. Retrieved May 23, 2010, from www.jointcommission.org/PatientSafety/

Krefting, L. (1991). Rigor in qualitative research: The assessment of trustworthiness. American Journal of Occupational Therapy, 45, 214–222. [Article] [PubMed]

Krueger, R. A., & Casey, M. A. (2000). Focus groups: A practical guide for applied research (3rd ed.). Thousand Oaks, CA: Sage.

Lohman, H., Mu, K., & Scheirton, L. (2004). Occupational therapists’ perspectives on practice errors in geriatric practice settings. Physical and Occupational Therapy Practice in Geriatrics, 21, 21–39. [Article]

Morse, J. M., & Field, P. A. (1995). Qualitative research methods for health professionals. Thousand Oaks, CA: Sage.

Mu, K., Lohman, H., & Scheirton, L. (2005, September 19). To err is human. OT Practice, pp. 13–16.

Mu, K., Lohman, H., & Scheirton, L. (2006). Occupational therapy practice errors in physical rehabilitation and geriatrics settings: A national survey study. American Journal of Occupational Therapy, 60, 288–297. doi: 10.5014/ajot.60.3.288 [Article] [PubMed]

National Patient Safety Foundation. (2010). Our mission. Retrieved May 23, 2010, from www.npsf.org/au/mission_vision.php

Patient Safety and Quality Improvement Act of 2005, Pub. L. 109–41, 42 U.S.C. § 299b.

Sandstrom, R. W., Lohman, H., & Bramble, J. D. (2009). Heath services: Policy and systems for therapists (2nd ed.). Upper Saddle River, NJ: Pearson Education.

Scheirton, L., Mu, K., & Lohman, H. (2003). Occupational therapists’ responses to practice errors in physical rehabilitation settings. American Journal of Occupational Therapy, 57, 307–314. doi: 10.5014/ajot.57.3.307 [Article] [PubMed]

U.S. Department of Veterans Affairs. (2010). VA National Center for Patient Safety. Retrieved May 23, 2010, from www.patientsafety.gov/

Vincent, C. (2006). Patient safety. London: Churchill Livingstone.

World Health Organization. (2009a). Global priorities for patient safety research: Better knowledge for safer care. Geneva, Switzerland: Author.

World Health Organization. (2009b). WHO patient safety research. Geneva, Switzerland: Author.

Table 1.

Participant Demographic Information

Characteristic	n	%
Gender
Male	3	8.8
Female	31	91.2
Age
20–29	2	5.9
30–39	7	20.6
40–49	14	41.2
50+	11	32.4
Practice area
Geriatrics	7	20.6
Physical rehabilitation	18	52.9
Both	7	20.6
No data	2	5.9
Experience, mean yr
Geriatrics	6.8
Physical rehabilitation	14.6
Location
Colorado	12	35.3
Nebraska	9	26.5
New York	6	17.6
North Carolina	7	20.6

View Large

Table 1.

Participant Demographic Information

Characteristic	n	%
Gender
Male	3	8.8
Female	31	91.2
Age
20–29	2	5.9
30–39	7	20.6
40–49	14	41.2
50+	11	32.4
Practice area
Geriatrics	7	20.6
Physical rehabilitation	18	52.9
Both	7	20.6
No data	2	5.9
Experience, mean yr
Geriatrics	6.8
Physical rehabilitation	14.6
Location
Colorado	12	35.3
Nebraska	9	26.5
New York	6	17.6
North Carolina	7	20.6